Publications by authors named "Tal Frenkel Rutenberg"

37 Publications

Unplanned excision of soft tissue sarcoma: does it impact the accuracy of intra-operative pathologic assessment at time of re-excision?

Int Orthop 2021 Aug 20. Epub 2021 Aug 20.

Musculoskeletal Oncology Division, Department of Orthopedic Surgery, Miller School of Medicine, University of Miami, Miami, FL, 33136, USA.

Purpose: An "unplanned excision" refers to soft tissue sarcomas excised without planning imaging studies and a diagnostic biopsy, resulting in the presence of residual disease and usually necessitating a re-excision procedure. We aimed to assess the impact of previous unplanned excisions on the intra-operative pathologic assessment at the time of re-excision, in terms of need to perform repeat assessments and the accuracy to predict margin status of the final pathologic specimen.

Methods: Data was collected for all patients with extremity soft tissue sarcoma who had undergone wide local excision limb salvage surgery or amputation between 2012 and 2017. Intra-operative pathologic assessment with frozen sections was performed in all cases and was classified as negative, negative but close (< 1 mm), and positive.

Results: A total of 173 patients with extremity soft tissue sarcoma were included, 54 in the unplanned excision group and 119 in the planned excision group. The accuracy of intra-operative pathologic assessment to predict the margin status on final pathology was similar between groups (87% unplanned vs. 90.7% planned excisions). However, the need for repeat intra-operative pathologic assessment and subsequent resection due to microscopically positive margins was found to be higher within the unplanned excision group ((p = 0.04), OR = 3.2 (95% CI: 1.1-9.1, p = 0.048)).

Conclusions: Intra-operative pathologic assessment of resection margins had a similar accuracy in planned and unplanned excisions; however, unplanned excisions showed a higher risk of re-resection during the same surgical setting.
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http://dx.doi.org/10.1007/s00264-021-05187-yDOI Listing
August 2021

Lateral Column Lengthening for Flexible Flat Foot: Was It Short to Begin With?

Isr Med Assoc J 2021 Aug;23(8):506-509

Department of Orthopedic Surgery and Traumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel& Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Flexible flatfoot (FF) is a common foot deformity that can often consist of foot pain. Surgical treatment is designed to lengthen the lateral column.

Objectives: To resolve whether radiographic standing feet measurements of normo-plantigrade feet and FF, symptomatic or not, differ and to determine whether the lateral column is shorter.

Methods: The study comprised 72 patients (127 feet) consecutive patients, 18 years of age and older, who were divided into three groups: normal feet (56), asymptomatic FF (29), and symptomatic FF (42). All patients had a standing anterior posterior (AP) and lateral radiographs. AP images were used for the measurement of the talocalcaneal angle, talar-1st metatarsal angle, and talonavicular coverage. Lateral X-rays were used to estimate the talocalcaneal angle, talar-1st metatarsal angle, calcaneal pitch, naviculocuboid overlap, and column ratio.

Results: All three of the AP radiograph measurements differed among groups, and higher values were measured in the symptomatic FF group. Post hoc analysis found that the talonavicular coverage and the talocalcaneal angles also differed between symptomatic and asymptomatic FF patients. While some lateral measurements differed within groups, only the lateral talar-1st metatarsal angle distinguished between asymptomatic and symptomatic patients. The lateral column length was not found to be shorter among FF patients, weather symptomatic or not.

Conclusions: Only the talonavicular coverage, the AP talocalcaneal, and the lateral talar-1st metatarsal angles were found to differ between asymptomatic and symptomatic FF patients. The lateral column was not found to be shorter.
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August 2021

The Impact of the COVID-19 2020 Pandemic on Hospital Length of Stay Following Fragility Hip Fracture Surgery.

Isr Med Assoc J 2021 Aug;23(8):469-474

Department of Orthopedic Surgery and Traumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel.

Background: Hip fractures in elderly patients are a major cause of morbidity and mortality. Variability in length of hospital stay (LOS) was evident in this population. The coronavirus disease-2019 (COVID-19) pandemic led to prompt discharge of effected patients in order to reduce contagion risk. LOS and discharge destination in COVID-19 negative patients has not been studied.

Objectives: To evaluate the LOS and discharge destination during the COVID-19 outbreak and compare it with a similar cohort in preceding years.

Methods: A retrospective study was conducted comparing a total of 182 consecutive fragility hip fracture patients operated on during the first COVID-19 outbreak to patients operated on in 2 preceding years. Data regarding demographic, co-morbidities, surgical management, hospitalization, as well as surgical and medical complications were retrieved from electronic charts.

Results: During the pandemic 67 fragility hip fracture patients were admitted (COVID group); 55 and 60 patients were admitted during the same time periods in 2017 and 2018, respectively (control groups). All groups were of similar age and gender. Patients in the COVID group had significantly shorter LOS (7.2 ± 3.3 vs. 8.9 ± 4.9 days, P = 0.008) and waiting time for a rehabilitation facility (7.2 ± 3.1 vs. 9.3 ± 4.9 days, P = 0.003), but greater prevalence of delirium (17.9% vs. 7% of patients, P = 0.028). In hospital mortality did not differ among groups.

Conclusions: LOS and time to rehabilitation were significantly shorter in the COVID group. Delirium was more common in this group, possibly due to negative effects of social distancing.
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August 2021

Do cancer patients undergoing surgery for a non-neoplastic related fragility hip fracture have worse outcomes? A retrospective study.

Arch Orthop Trauma Surg 2021 Jun 7. Epub 2021 Jun 7.

Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Introduction: An increasing number of patients sustaining a fragility hip fracture (FHF) have either an active diagnosis or a history of cancer. However, little is known about the outcomes of non-malignant related FHF in this group of patients. We aimed to evaluate the mortality and complications rates during hospitalization, as well as at 1-year follow-up within this population.

Methods: A retrospective cohort study of patients 65 years of age and above, who underwent surgery for the treatment of proximal femoral fractures between January 2012 and June 2016 was conducted. Patients diagnosed with malignancies, both solid (Carcinomas) and a hematological neoplasias (Lymphomas, Multiple Myeloma) were included, along with consecutive controls without a diagnosis of cancer in the 5 years prior to the study period. Demographic, clinical and radiographic parameters were recorded and analyzed.

Results: Seven hundred and fifty-two patients with FHF were included, of whom 51 had a malignancy diagnosis within the 5-year period preceding the fracture (18% metastatic disease). The mean time from malignancy diagnosis to FHF was 4.3 ± 4.8 years. Time to surgery did not differ between groups, and the vast majority of patients from both groups (over 87%) were operated within the desirable 48 h from admission. Patients with malignancy had a higher probability of being admitted to an internal medicine department both pre and post-surgically (p < 0.001), and were more susceptible to pre-operative anemia (p = 0.034). In-hospital mortality did not differ between groups, yet 1-year mortality was higher for the malignancy group (41.2% vs 19.5%, p < 0.001). At 1-year post-operatively, orthopedic complications were similar between groups.

Conclusion: Patients with a history of malignancy in the 5-years prior to a non-neoplastic FHF, showed similar mortality and complications rates during admission but increased 1 year mortality rate when compared to patients without cancer undergoing surgical treatment of a non-neoplastic proximal femoral fracture.
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http://dx.doi.org/10.1007/s00402-021-03976-zDOI Listing
June 2021

Treatment of Peripheral Nerve Injuries in Syria's War Victims: Experience from a Northern Israeli Hospital.

Isr Med Assoc J 2021 May;23(5):279-285

Department of Orthopedic Surgery and Traumatology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel.

Background: The collapse of the Syrian healthcare system during the civil war led numerous citizens to cross the Syrian-Israeli border to seek medical care.

Objectives: To describe the epidemiology of peripheral nerve injuries (PNIs) sustained in war, their management, and short-term outcomes.

Methods: A retrospective case series study was conducted on 45 consecutive patients aged 25.7 ± 9.3 years. These patients were referred to the hand surgery unit of the department of orthopedic surgery and traumatology at Galilee Medical Center between December 2014 and June 2018. Median time between injury and presentation was 60 days. Injury pattern, additional injuries, surgical findings and management, complications, and length of hospital stay were extracted from medical records.

Results: Most injuries were blast (55.6%) followed by gunshot injuries (37.8%). There were 9 brachial plexus injuries, 9 sciatic nerve injuries, and 38 PNIs distal to the plexus: specifically 20 ulnar, 11 median, and 7 radial nerve injuries. In the latter group, neurotmesis or axonotmesis was found in 29 nerves. Coaptation was possible in 21 nerves necessitating cable grafting in 19. A tendon transfer was performed for 13 peripheral nerves, occasionally supplementing the nerve repair. The patients returned to their country after discharge, average follow-up was 53.6 ± 49.6 days.

Conclusions: For nerve injuries sustained in war, early surgical treatment and providing adequate soft tissue conditions is recommended. Tendon transfers are useful to regain early function.
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May 2021

Are extracapsular and intracapsular hip-fracture patients two distinct rehabilitation subpopulations?

Disabil Rehabil 2021 May 13:1-6. Epub 2021 May 13.

Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.

Purpose: To assess whether intracapsular and extracapsular hip fracture patients in a post-acute rehabilitation setting differ in their background characteristics and whether fracture type affects rehabilitation outcome.

Methods: A retrospective cohort study.

Outcome Measures: Functional Independence Measure (FIM), motor FIM (mFIM), mFIM effectiveness, length of stay (LOS), and discharge destination. Various tests assessed associations (the Mann-Whitney , the chi-square, logistic regression), population differences (-test), and independent predictors of discharge FIM score (multiple linear regression model).

Results: Six hundred and eighty-seven patients completed the rehabilitation program. The intracapsular hip fracture patient group was characterized by significantly higher percentages of males, higher education levels, and living with a caregiver compared with the extracapsular hip fracture patient group. Intracapsular hip fracture patients were younger, had longer latency time from fracture to surgery, exhibited higher functional levels on admission and upon discharge, higher cognitive function and shorter rehabilitation time than extracapsular hip fracture patients. Both study groups possessed similar comorbidities, rehabilitation achievements, and discharge destination. Regression analyses showed that the fracture type was not associated with discharge FIM score, nor with the probability of achieving a favorable functional gain.

Conclusions: Post-acute extracapsular and intracapsular hip fracture patients are demographically and clinically two distinct subpopulations. Nevertheless, given additional time, extracapsular hip fracture patients will attain similar functional achievements as intracapsular hip fracture patients.Implications for rehabilitationPost-acute extracapsular and intracapsular hip fracture patients are demographically and clinically two distinct subpopulations.Given additional time, extracapsular hip fracture patients can attain similar functional achievements as intracapsular hip fracture patients.
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http://dx.doi.org/10.1080/09638288.2021.1919214DOI Listing
May 2021

Dynamic locking plate vs. cannulated cancellous screw for displaced intracapsular hip fracture: A comparative study.

J Orthop 2021 Mar-Apr;24:15-18. Epub 2021 Feb 12.

Orthopedic Department, Tel Aviv Sourasky Medical Center, Ichilov Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Introduction: There is no consensus regarding the optimal device for displaced intracapsular hip fractures. This retrospective study compared two techniques (1) cannulated cancellous screw (CCS), and (2) Targon Femoral Neck (TFN) plate.

Materials And Methods: Data regarding gender, operational data, complications, pain, Quality of life and function scores were retrieved.

Results: 103 patients were included, 42 were treated using CCS, compared to 61 treated using TFN. Operative time shorter for CCS (p = 0.019). Complication rates were not different (p > 0.05).

Conclusion: As CCS method take shorter operating time and reduced costs, CCS should be used for the treatment of displaced ICHF.
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http://dx.doi.org/10.1016/j.jor.2021.02.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7902286PMC
February 2021

Expandable Proximal Femoral Nail versus Gamma Proximal Femoral Nail for the treatment of hip reverse oblique fractures.

Arch Orthop Trauma Surg 2021 Jan 8. Epub 2021 Jan 8.

Department of Orthopaedic Surgery, Medical Center, Affiliated with the Faculty of Health and Science and Ben Gurion University, Ha-Refu'a St 7, 7747629, Ashdod, Israel.

Background: Reverse oblique intertrochanteric fractures are classified by the AO/OTA as 31A3 and account for 2-23% of all trochanteric fractures. The Gamma 3-Proximal Femoral Nail (GPFN) and the Expendable Proximal Femoral Nail (EPFN) are among the various devises used to treat this fracture. The aim of this study was to compare outcomes and complication rates in patients with AO/OTA 31A1-3 fractures, treated by either a GPFN or an EPFN.

Patients And Methods: A total of 67 patients (40 in the GPFN group and 27 in the EPFN group, average age 78.8 years) were treated in our institution between July 2008 and February 2016. Data on postoperative radiological variables, including peg location and tip-apex distance (TAD), as well as orthopedic complications, such as union rate, surgical wound infection and cut-outs rates were also recorded, along with the incidence of non-orthopedic complications and more surgical data. Functional results were evaluated and quantified using the Modified Harris Hip Score (MHHS) and by the Short Form 12 Mental Health Composite questionnaire (SF-12 MHC) in order to assess the quality of life.

Results: The total prevalence of postoperative orthopedic complications including postoperative infection showed a significant difference with a p-value of 0.016 in favor of the EPFN group. Nonetheless, the frequency of revision did not differ between the two groups, being 0.134. The main orthopedic complication in both groups was head cut-out of the GPFN lag screw and the EPFN expendable peg, which was 20% and 7.4%, respectively, and required a revision surgery using a long nail or total hip replacement (THR). However, the average TAD did not significantly differ between groups which might be due to a relatively low cohort to reach a significant difference. Nonunion rate of 5% occurred solely in the GPFN group, with similar results of intraoperative open reduction between both groups. The EPFN group achieved better scores in both questionnaires (p = 0.027 and p = 0.046, respectively). Both the MHHS and SF-12 MCS values significantly differed between groups, with the EPFN group achieving better scores than the GPFN group in both questionnaires (p = 0.027 and p < 0.05, respectively).

Conclusions: According to this study, the EPFN yields better results in comparison with the GPFN, with relatively less complications rate, for the treatment of unstable reverse oblique pertrochanteric fracture. In light of this results, we conclude that the EPFN might be as good as GPFN for the treatment of reverse oblique intertrochanteric fractures.

Level Of Evidence: Level III retrospective study. The local institutional review board of the Tel Aviv Medical Center approved this study and all the surgeries were done exclusively in this institution.
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http://dx.doi.org/10.1007/s00402-020-03726-7DOI Listing
January 2021

Outcome of fragility hip fractures in elderly patients: Does diabetes mellitus and its severity matter?

Arch Gerontol Geriatr 2021 Mar-Apr;93:104297. Epub 2020 Nov 18.

Orthopedic Department, Rabin Medical Center, Beilinson Hospital, affiliated to the Sackler Faculty of Medicine, Aviv University, Tel Aviv, Israel.

Aims: Diabetes mellitus (DM) and osteoporosis are both diseases of epidemic proportions with an increasing incidence worldwide. Fragility hip fractures (FHF) are associated with elevated morbidity, mortality, social burden and medical costs. The aim of this study was to determine whether patients with DM have worse medical and surgical outcomes following FHFs and whether the Diabetes Complications Severity Index (DCSI) can predict in-hospital complications and one-year mortality.

Methods: A single centre retrospective cohort study including 1343 patients older than 65 years who underwent surgery for FHFs was conducted. The data collected included length of hospital stay, time-to-surgery, blood loss, complications and mortality during the first post-operative year.

Results: 408 patients with a DM diagnosis were compared with 935 without DM. Pre-operatively, patients with DM had lower haemoglobin levels, higher platelet counts and worse renal function. Following surgery, patients with DM were more likely to be transferred to another department or intensive care. One-year mortality was significantly higher in the DM group [23.3% vs. 17.1%, odds ratio 1.36 (CI 1.029-1.799, p = 0.03)]. Higher DCSI scores were related with elevated one-year mortality rates in the DM group. Cerebrovascular events were found to be nearly five times more prevalent in the DM group. Patients with DM were more likely to continue treatment in a rehabilitation centre and had a higher probability to be re-hospitalized in the first post-operative year (p.<0.001).

Conclusions: Our results emphasize the increased vulnerability of this patient population and the importance of specialized care during the peri-operative period of FHFs.
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http://dx.doi.org/10.1016/j.archger.2020.104297DOI Listing
February 2021

Antibiotic prophylaxis as a quality of care indicator: does it help in the fight against surgical site infections following fragility hip fractures?

Arch Orthop Trauma Surg 2020 Nov 20. Epub 2020 Nov 20.

Department of Management, Bar Ilan University, Public Health MHA Program, Ramat Gan, Israel.

Introduction: Fragility hip fractures are associated with increased morbidity, mortality, and costs. To improve patient care, quality indicator programs were introduced. Yet, the efficacy of these programs and specific quality indicators are questioned. We aimed to determine whether defining prophylactic pre-surgical antibiotic treatment as a quality indicator affected hip fracture outcomes.

Materials And Methods: A retrospective study comparing consecutive patients, 65 years and older, who were operated for fragility hip fractures between 01/01/2011 and 30/06/2016, before and after the prophylactic pre-surgical antibiotic treatment quality indicator, which was introduced in 01/2014. Primary outcomes were 1-year surgical site infections (SSI). Secondary outcomes were meeting the quality index and mortality rates, either within a hospital or during the first post-operative year.

Results: 904 patients, ages 82.5 ± 7.2 years were operated for fragility hip fractures. 403 patients presented before the antibiotic prophylaxis quality indicator, and 501 following its administration. Patients demographics were comparable. In the pre-quality indicator period, documentation of prophylactic antibiotic treatment was lacking. Only 19.6% had a record for antibiotic administration in their surgical records and for merely 10.4% the type of antibiotic was stated. However, in the post-quality indicator period, 97.0% of patients had a registered prophylactic antibiotic regimen in the hour preceding the surgical incision (p  < 0.001). Post-operative SSI rates were equivalent, and as were in-hospital infections, mortality and recurrent hospitalizations CONCLUSIONS: The introduction of the pre-operative antibiotic treatment quality indicator increased the documentation of antibiotic administration yet failed to influence the incidence of post-operative orthopaedic and medical infections in fragility hip fracture patients.
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http://dx.doi.org/10.1007/s00402-020-03682-2DOI Listing
November 2020

Earlier Initiation of Postoperative Physical Therapy Decreases Opioid Use after Total Knee Arthroplasty.

J Knee Surg 2020 Nov 9. Epub 2020 Nov 9.

Orthopedic Department, Rabin Medical Center, HaSharon Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

For patients with advanced osteoarthritis of the knee, total knee arthroplasty (TKA) has been shown to provide significant pain relief and improved function with consistent, reproducible results. Post-operative physical therapy (PT) plays an important role is restoring muscle strength and range of motion (ROM). Yet, the impact of earlier physical therapy initiation after TKA has not been well defined. We assessed 205 patients that underwent primary TKA including 136 patients who started PT on the first post-operative day (POD1) and a second group that started PT 3 days after surgery (POD3), or later. Length of hospital stay (LOS), opioid use during hospital stay, complications, re-admissions, knee ROM and the need for subsequent hospitalized rehabilitation were recorded. LOS was not significantly shorter in the early PT group, compared with the delayed PT group (6.4 ± 2.2 days vs. 6.8 ± 2 days, respectively,  = .217). Patients in the delayed PT group consumed more opioids during their inpatient stay compared with the early PT group on both POD 3 (89% vs 82%,  = 0.013) and POD 4 (81% vs 66%,  = 0.005). There was no significant difference in the incidence of Immediate post-operative complications or final knee ROM between the two groups. While early postoperative PT did not impact hospital LOS or final knee ROM, it was associated with an earlier reduction in postoperative opioid consumption after primary TKA.
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http://dx.doi.org/10.1055/s-0040-1721034DOI Listing
November 2020

Revision total knee arthroplasty for patellar dislocation in patients with malrotated TKA components.

Arch Orthop Trauma Surg 2020 Jun 5;140(6):777-783. Epub 2020 May 5.

Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.

Purpose: Patellar dislocation is a serious complication leading to patient morbidity following total knee arthroplasty (TKA). The cause can be multifactorial. Extensor mechanism imbalance may be present and result from technical errors such as malrotation of the implants. We sought to understand the reasons for post-arthroplasty patellar dislocation and the clinical outcomes of patients in whom it occurs.

Methods: This is a retrospective cohort study assessing the outcomes of revision surgery for patellar dislocation in patients with component malrotation in both primary and revision TKAs. Patient demographics, dislocation etiology, presurgical deformity, intraoperation component position, complications, reoperation, and Knee Society Scores (KSS) were collected.

Results: Twenty patients (21 knees) were identified. The average time from primary arthroplasty to onset of dislocation was 33.6 months (SD 44.4), and the average time from dislocation to revision was 3.38 months (SD 2.81). Seventeen knees (80.9%) had internal rotation of the tibial component and seven knees (33.3%) had combined internal rotation of both the femoral and tibial components. Fifteen knees (71.4%) were treated with a condylar constrained implant at the time of revision, and five knees were converted to a hinged prosthesis. The average follow-up time was 56 months. During this time, one patient (4.54%) had a recurrent dislocation episode, requiring further surgery. At final follow up, the mean KSS was 86.2.

Conclusion: Revision TKA following patellar dislocation for patients with malrotated components was associated with high success rates. After revision surgery, patients had a low recurrence of patellar dislocation, low complication rates, and excellent functional outcomes.
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http://dx.doi.org/10.1007/s00402-020-03468-6DOI Listing
June 2020

Impact of the Holocaust on the outcomes of elderly patients sustaining a fragility hip fracture.

Arch Orthop Trauma Surg 2021 Jan 2;141(1):39-44. Epub 2020 May 2.

Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 39 Jabotinsky St., 49100, Petah Tikva, Israel.

Introduction: Holocaust survivors (HS) were under an immense continues physical and mental stressors in their younger years, putting them at increased risk for both fragility hip fractures and worse medical and functional outcomes. We aimed to evaluate whether being a HS could affect the functional outcomes of fragility hip fractures in patients 80 years of age and older following surgery.

Materials And Methods: A retrospective study comparing consecutive patients, 80 years and older, who were operated for fragility hip fractures between 2011 and 2016. HS survival status was self-defined by survivors who were born in European and northern African countries that were later occupied by the Nazi regime during World War II and experienced incarceration in concentration camps, forced labor camps and mass transport. Primary outcomes were mortality either within hospital or in the post-operative year. Secondary outcomes were in-hospital complications, recurrent hospitalizations and orthopedic complications within the post-operative year.

Results: Two hundred thirty-one HS and 339 controls, ages 86.4 ± 4.4 years who were operated for fragility hip fracture between January 2011 to June of 2016 were included in the study. Patients from both groups were of similar age, Carlson's co-morbidity index score, leaving arrangement and pre-fracture mobility. Among HS there were more women (p = 0.029). HS did not have lower survival rates either within hospital or in the post- operative year. Both length of stay and in-hospital complication rates were similar between groups. In the post-operative year, HS were less likely to be hospitalized than controls (p = 0.021). The rate of orthopedic complications was also similar.

Conclusions: Holocaust survivors patients do not achieve worse outcome following fragility hip fracture surgery and present distinctive resilience.
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http://dx.doi.org/10.1007/s00402-020-03459-7DOI Listing
January 2021

Platelet-Rich Plasma for Knee Osteoarthritis: Internet Marketing and Patient Education-An Appraisal of Content for Websites with the Greatest Search Engine Visibility.

Cartilage 2020 Feb 19:1947603520906598. Epub 2020 Feb 19.

Department of Orthopedic Surgery, Beilinson Campus, Rabin Medical Center, Petah-Tikva, Israel.

Objective: The internet is increasingly being used as a resource for health-related information by the general public. We sought to establish the authorship, content, and accuracy of the information available online regarding platelet-rich plasma (PRP) therapy for knee osteoarthritis.

Design: Top 200 search results from each of the 3 leading search engines available online (Google, Yahoo!, Bing) were screened, and 181 websites were finally reviewed for content with emphasis on specific claims, comparing between websites authored by private physicians/groups and other authorship types.

Results: Nearly 80% of the websites claimed that PRP injections for osteoarthritis of the knee improve patients' pain. A total of 42.8% of the private websites and 27.6% of nonprivate websites have stated that the procedure can delay or eliminate the need for future surgery. Costs were only mentioned by few (11.6%), and mainly by the nonprivate websites. Both website groups were unlikely to mention that PRP therapy is not the treatment of choice for end-stage knee osteoarthritis (7.9% of private and 17.2% of the nonprivate sites), or to state that patients with less advanced disease may benefit more from the treatment (11.8% and 20.6%, respectively). Private websites were less likely to refer to peer-reviewed literature (18.4% vs. 41.4%) and were more than 3 times less likely to mention lack of adequate evidence (13.2% vs. 48.2%).

Conclusions: Patients seeking online information regarding PRP therapy are vulnerable to websites presenting a narrow viewpoint of this treatment modality, putting emphasis on unsubstantiated benefits while disregarding potential drawbacks and concerns.
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http://dx.doi.org/10.1177/1947603520906598DOI Listing
February 2020

The Role of 18F-Fluorodeoxyglucose Positron-Emission Tomography/Computed Tomography in the Diagnosis of Postoperative Hardware-Related Spinal Infections.

Isr Med Assoc J 2019 Aug;21(8):532-537

Department of Orthopedics, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel.

Background: Implant-related spinal infections are a surgical complication associated with high morbidity. Due to infection, hardware removal may be necessary, which could lead to pseudarthrosis and the loss of stability and alignment.

Objectives: To evaluate the accuracy and diagnostic value of 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) in the workup of patients with suspected implant-related infections of the spine and to assess the clinical impact of PET/CT results on the management of these infections.

Methods: The study included nine consecutive patients with a history of spinal surgery who underwent PET/CT for evaluation of suspected spinal implant related infection. All imaging studies were performed between January 2011 and December 2013. All 18F-FDG PET/CT scans were performed on an 8 slice PET/CT following an 18F-FDG injection. Images were scored both visually and semi-quantitatively by a radiology expert. Results were compared to additional imaging studies when available, which were correlated to clinical and bacteriological findings allowing calculation of sensitivity, specificity and accuracy.

Results: Among the patients, five experienced hardware-related spinal infection. 18F-FDG PET/CT sensitivity was 80%, specificity 100%, and accuracy 88.9%. One scan produced a false negative; however, a second PET/CT scan revealed an infection.

Conclusions: PET/CT was found to be valuable for the diagnosis of postoperative hardware-related spinal infection, especially when other imaging modalities were uninformative or inconclusive. As such, PET/CT could be useful for management of infection treatment.
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August 2019

Conservative treatment for pyogenic flexor tenosynovitis: a single institution experience.

J Plast Surg Hand Surg 2020 Feb 27;54(1):14-18. Epub 2019 Aug 27.

Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Pyogenic flexor tenosynovitis (PFT) of the hand is a common infection which is clinically diagnosed using Kanavel's signs. Delay in diagnosis and treatment may lead to devastating outcomes, including reduced range of motion (ROM), deformities, tendon impairment or even amputation. While the gold standard for treatment is irrigation and debridement of the flexor sheath, little is known about the outcomes of conservative treatment with intravenous (IV) antibiotics. Patients treated conservatively for PFT between 2000 and 2013 were included. Demographic information, co-morbidities and clinical features at presentation such as Kanavel's signs and inflammatory markers levels were gathered. Treatment course, length of stay (LOS), functional outcomes and complications were collected. Fifty-four (54) patients presented with PFT in the study period. Forty-six (46) patients, ages 19-84 years old, who were treated conservatively were included. Average time from symptoms onset to presentation was 4.6 ± 7.1 days. Fourteen (14) patients failed to improve with course of oral antibiotics prior to presentation. The average number of Kanavel's signs was 3 ± 0.7. Inflammatory markers were elevated in 82.2% of patients. The mean LOS was 4.7 ± 2 days. Forty-four (44) patients continued follow-up for 55 ± 45 months. Final flexion ROM was full or minimally limited in 69% of patients. Three patients were eventually operated. Complication rate for the entire cohort was 4.3% and no fingers were lost. This retrospective case series indicate that inpatient empirical IV antibiotic therapy can be considered for patients presenting with uncomplicated PFT, provided it is practiced under a hand specialist's surveillance.
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http://dx.doi.org/10.1080/2000656X.2019.1657434DOI Listing
February 2020

Outcome of non-surgical treatment of proximal femur fractures in the fragile elderly population.

Injury 2019 Jul 22;50(7):1347-1352. Epub 2019 May 22.

Department of Orthopedics, Rabin Medical Center, Beilinson Hospital, Petah, Tikva, Israel.

Introduction: With the aging of the population the rate of fragility hip fractures increases. While medical recommendations are for hasten surgical treatment, for some older patients burdened with severe comorbidities, this might be risky.

Aims: To compare the outcomes of patients treated non-surgically to those of the most fragile patients treated surgically.

Patients And Methods: A retrospective cohort study, of individuals aged ≥65 years who presented with fragility hip fractures between 01.01.2011-30.06.2016, to a primary trauma center. Patients treated surgically were stratified according to their age-adjusted Charlsons' comorbidity index (ACCI) score. Patients in the upper third of ACCI score, representing the more fragile population, were compared to patients treated non-surgically.

Results: 847 patients presented with fragility fractures. 94 (11%) were treated non-surgically and 753 (89%) underwent surgery. Medical reasons were the leading cause for non-surgical treatment (61.7%). Surgically-treated patients were stratified according to their ACCI and 114 patients with ACCI > 9 were chosen for comparison. While both groups were comparable in terms of age, the non-surgical treatment group had more female patients (p. = 0.026) and a smaller proportion of independent walkers (p < 0.001). The ACCI was higher for the surgical treatment group (p < 0.001). In-hospital mortality was similar (14.9% and 18.1% for the operative and non-surgical groups respectively, P. = 0.575). However, one-year mortality was significantly higher for the non-surgical group (48.2% vs. 67.0%, P. = 0.005). The rates of in-hospital complications and 1-year readmissions were similar.

Conclusions: Operative treatment for fragility hip fracture reduces long-term mortality rates even in the more fragile patients, compared to non-surgical treatment.
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http://dx.doi.org/10.1016/j.injury.2019.05.022DOI Listing
July 2019

Surgical Site Infections in Elderly Fragility Hip Fractures Patients Undergoing Warfarin Treatment.

J Orthop Trauma 2019 Oct;33(10):518-524

Department of Orthopedics, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.

Objectives: Surgical site infection (SSI) is a devastating complication of proximal femoral fracture surgery, related with an increased morbidity and mortality. As warfarin treatment has been described as a risk factor for SSI, we aimed to compare patient and SSI characteristics in warfarin and nonanticoagulated patients.

Design: Retrospective cohort study.

Setting: Level-1 trauma center.

Patients: Individuals 65 years of age and older with fragility hip fractures.

Intervention: Patients were divided into 2 cohorts: warfarin treated (n = 85) or nonanticoagulated (n = 771). Demographics, in-hospital characteristics, laboratory data, prior hospitalizations, recent antibiotic use, and 1-year incidence of SSIs and their characteristics were gathered.

Main Outcome Measures: Postoperative SSIs.

Results: Twelve patients (14.1%) from the warfarin group and 21 patients (2.7%) from the noncoagulated group had SSI (P < 0.001). Both groups were comparable in terms of demographics and Charlson comorbidity score. Warfarin-treated patients had reduced white blood and neutrophils counts (10.1 ± 3.2 vs. 11.6 ± 4.0 cells/mm and 8.1 ± 3.2 vs. 9.6 ± 3.9 cells/mm for both comparisons respectively; P < 0.001 for both). They were more likely to be admitted to a geriatric ward than to orthopedics ward and were delayed to theater (58.5 ± 44.5 vs. 30.6 ± 27.4 hours; P < 0.001). Following surgery, there was no difference in blood transfusions required, in-hospital complications, or time to infection. Rates of prior hospitalizations, antibiotic use, or type of bacteria did not differ.

Conclusions: Warfarin treatment in fragility hip fracture surgery is correlated with an increased risk for SSI, regardless of in-hospital complications, and hospitalizations before surgery or to the infection itself.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001508DOI Listing
October 2019

Surgical treatment of low-grade chondrosarcoma involving the appendicular skeleton: long-term functional and oncological outcomes.

Arch Orthop Trauma Surg 2019 Dec 24;139(12):1659-1666. Epub 2019 Apr 24.

Department of Orthopaedic Surgery, Musculoskeletal Oncology Division, University of Miami-Miller School of Medicine, 1400 NW 12th Avenue, East Building, 4th Floor, Suite 4036, Miami, FL, USA.

Background: The traditional treatment for chondrosarcoma is wide local excision (WLE), as these tumors are resistant to chemotherapy and radiation treatment. While achieving negative margins has traditionally been the goal of chondrosarcoma resection, multiple studies have demonstrated good short-term results after intralesional procedures for low-grade chondrosarcomas (LGCS) with curettage and adjuvant treatments (phenol application, cauterization or cryotherapy) followed by either cementation or bone grafting. Due to the rarity of this diagnosis and the recent application of this surgical treatment modality to chondrosarcoma, most of the information regarding treatment outcomes is retrospective, with short or intermediate-term follow-up. The aim of this study was to assess the long-term results of patients with LGCS of bone treated with intralesional curettage (IC) treatment versus WLE. This retrospective analysis aims to characterize the oncologic outcomes (local recurrence, metastases) and functional outcomes in these two treatment groups at a single institution.

Methods: Using an institutional musculoskeletal oncologic database, we retrospectively reviewed medical records of all patients with LGCS of the appendicular skeleton that underwent surgical treatment between 1985 and 2007. Thirty-two patients (33 tumors) were identified with LGCS; 17 treated with IC and 15 with WLE.

Results: Seventeen patients (18 tumors) with a minimum clinical and radiologic follow-up of 10 years were included. Nine patients were treated with IC (four with no adjuvant, three with additional phenol, one with liquid nitrogen and one with HO) with either bone graft or cement augmentation, and nine others were treated with WLE and reconstruction with intercalary/osteoarticular allograft or megaprosthesis. The mean age at surgery was 41 years (range 14-66 years) with no difference (p = 0.51) between treatment cohorts. There was a mean follow-up of 13.5 years in the intralesional cohort (range 10-19 years) and 15.9 years in the WLE cohort (range 10-28 years, p = 0.36). Tumor size varied significantly between groups and was larger in patients treated with WLE (8.2 ± 3.1 cm versus 5.4 ± 1.2 cm, at the greatest dimension, p = 0.021). There were two local recurrences (LR), one in the intralesional group and one in the wide local excision group, occurring at 3.5 months and 2.9 years, respectively, and both required revision. No further LR could be detected with long-term follow-up. The MSTS score at final follow-up was significantly higher for patients managed with intralesional procedures (28.7 ± 1.7 versus 25.7 ± 3.4, p = 0.033). There were less complications requiring reoperation in the intralesional group compared with the wide local excision group, although this difference was not found to be statistically significant (one versus four patients, respectively; p = 0.3).

Conclusion: This series of low-grade chondrosarcoma, surgically treated with an intralesional procedures, with 10-year follow-up, demonstrates excellent local control (88.9%). Complications were infrequent and minor and MSTS functional scores were excellent. Wide resection of LGCS was associated with lower MSTS score and more complications. In our series, the LR in both groups were detected within the first 3.5 years following the index procedure, and none were detected in the late surveillance period.
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http://dx.doi.org/10.1007/s00402-019-03184-wDOI Listing
December 2019

Correlation between preoperative imaging parameters and postoperative basic kinematics-based functional outcome in patients with tibial plateau fractures.

Clin Biomech (Bristol, Avon) 2019 05 16;65:87-91. Epub 2019 Apr 16.

Division of Orthopedics, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.

Background: Functional scores and radiographs are often used to assess function and predict development of osteoarthritis in patients with multi-fragmentary tibial plateau fractures (TPFs). Locomotion, which is the primary goal of fracture treatment, is rarely assessed. The objective of this study was to assess functional ability of patients after TPF fixation using spatio-temporal gait analysis (STGA), and to compare STGA variables with self-reported functional scores and preoperative fracture characteristics.

Methods: Preoperative CT scans of 21 patients with complete articular multi-fragmentary TPFs were evaluated for number of fragments, maximum gap between the fragments and maximum articular depression. All patients underwent STGA (velocity, cadence, step length of the affected and the unaffected leg, single-limb support by the affected and the unaffected leg, and double-leg support) and filled the Knee Society Score and the Short Form-12 questionnaires on average 3 years (SD = 1.56, range, 2-5.8) post-injury.

Findings: Step length and single-limb support time of the affected leg were shorter compared to the unaffected leg (p = 0.02 and p = 0.007, respectively). Number of fracture fragments correlated with cadence (R = -0.461, p = 0.04) and velocity (R = -0.447, p = 0.04).

Interpretation: Given that both higher fracture comminution and deformity on the one hand and the above gait parameter alterations on the other hand are associated with knee osteoarthritis, STGA may be used for routine postoperative evaluation of patients after TPF fixation.
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http://dx.doi.org/10.1016/j.clinbiomech.2019.04.009DOI Listing
May 2019

Rate and Outcome of Acute Kidney Injury Following Hip Fracture Surgery in Diabetic Older Patients Treated with Renin-Angiotensin-Aldosterone Antagonists.

Drugs Aging 2019 07;36(7):667-674

Department of Geriatrics, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel.

Background: The use of renin-angiotensin-aldosterone system inhibitors has increased over the past few years. There are conflicting data as to their relationship with acute kidney injury following surgery.

Objectives: The objective of the article was to evaluate the risk of acute kidney injury in diabetic older patients treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers and their medical outcomes following fragility hip fracture surgery.

Methods: Consecutive diabetic patients presenting with fragility hip fractures to our primary trauma center between January 2012 and June 2016 were included. Demographic and clinical data, including co-morbidities, medication use, and laboratory results, were collected from the electronic medical records. The primary outcome was the incidence of acute kidney injury; the secondary outcome was 1-year mortality.

Results: Two hundred and seventeen patients were included; 125 were receiving treatment with medications targeting the renin-angiotensin-aldosterone system. Demographic and clinical characteristics were similar between groups. No association was found between the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and the risk of acute kidney injury, which occurred in 25% of the cohort. Univariate analysis revealed that diuretic use, particularly furosemide, increased the risk of acute kidney injury during hospitalization (p = 0.003). However, in a multivariate analysis, only age and estimated glomerular filtration rates were associated with an increased risk of acute kidney injury. Patients with acute kidney injury were found to have increased mortality during the first post-operative year (p < 0.001).

Conclusions: Acute kidney injury is a frequent complication after hip fracture surgery in elderly diabetic patients and is associated with increased 1-year mortality; however, it was not found to be associated with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker pre-fracture treatment.
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http://dx.doi.org/10.1007/s40266-019-00671-yDOI Listing
July 2019

Which patients are less likely to improve after arthroscopic rotator cuff repair?

Acta Orthop Traumatol Turc 2019 Sep 8;53(5):356-359. Epub 2019 Mar 8.

Orthopedic Department, Sackler Faculty of Medicine, Tel-Aviv University, Israel; Orthopedic Department, Hasharon Hospital, Rabin Medical Center, Petach-Tikva, Israel.

Objective: The aim of this study was to evaluate which specific factors influence the improvement in function and to estimate the time to obtain pain relief following arthroscopic rotator cuff repair.

Methods: A total of 97 patients (57 men and 40 women; mean age: 55.5 ± 9.3 years) who had arthroscopic rotator cuff repair between 2013 and 2016 were included into the study. Multivariable stepwise analysis included preoperative variables (age, gender, body mass index, comorbidities, occupation and participation in sports, Oxford shoulder score at baseline, preceding injury and duration of preoperative symptoms) and arthroscopic findings (size of rotator cuff tear, pathology of the long head of the biceps and cartilage lesions). The change in the Oxford shoulder score at the last follow-up was modeled as a function of the above predictor variables. The time to regain a visual analogue scale (VAS) under two points following surgery was considered the time to regain substantial pain relief.

Results: The mean follow-up time was 33.2 ± 14.4 months. Twenty three patients had partial thickness and seventy four had full thickness supraspinatus tears. In third of the patients the tears were defined as large full thickness. At the last follow-up the mean Oxford shoulder score improved from 13.8 ± 4.8 to 42.1 ± 7.2 points (P < 0.001). The mean VAS improved from a preoperative score of 6.7 ± 1.3 points to 1.5 ± 0.6 points postoperatively (P < 0.001) and 80 (83%) patients declared they were satisfied to have had the operation. The mean time interval for substantial pain relief was 4.9 ± 3.6 months. Patients with higher preoperative Oxford shoulder score and larger tear size were correlated with lesser improvement in Oxford shoulder score (R = 0.5, P = 0.001).

Conclusion: Arthroscopic rotator cuff repair improved pain and function at an average follow-up of three years. A substantial pain relief was regained within five months from surgery. Larger rotator cuff tear size and more favorable preoperative function were predictors of worse postoperative function.

Level Of Evidence: Level IV, Therapeutic study.
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http://dx.doi.org/10.1016/j.aott.2019.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819785PMC
September 2019

Prediction of readmissions in the first post-operative year following hip fracture surgery.

Eur J Trauma Emerg Surg 2020 Oct 23;46(5):939-946. Epub 2018 Aug 23.

Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 39 Jabotinsky St., Petah Tikva, 49100, Tel Aviv, Israel.

Purpose: To define risk factors for rehospitalization following fragility hip fractures and to create a predictive model.

Methods: A retrospective cohort study of patients 65 years and older, who were treated operatively following fragility hip fractures between 01.2011 and 06.2016. Patients were allocated into two study groups based on the occurrence of recurrent hospitalizations in the year following surgery. Demographic information, comorbidities, and in-hospital characteristics were collected, as was information regarding 1-year readmissions. Multivariate analysis of factors predictive of rehospitalizations was performed, followed by a logistic regression using all predictors with p < 0.05. A stepwise backwards elimination method was used to create the predictive model.

Results: Eight hundred and fifty-one patients were included; 369 (43.4%) had recurrent hospitalizations within the first post-operative year. Patients who were rehospitalized were more likely to be males, to use a walking aid and to live dependently. They had a higher age-adjusted Charlson's comorbidity index (ACCI) score, a higher perveance of atrial fibrillation, lower hemoglobin, worse renal function, less platelets, and longer time to surgery. Prevalence of in-hospital complications was similar. Six variables were found to independently influence the chance for readmissions: male gender, the use of a walking aid, higher ACCI score, lower hemoglobin, atrial fibrillation, and a longer surgical delay. Only the first four were found to be adequate predictors and were added to the prediction formula.

Conclusion: High 1-year readmission rates are seen following discharge in patients with fragility hip fractures. Addressing risk factors might aid to better rehabilitate patients and reduce morbidity.
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http://dx.doi.org/10.1007/s00068-018-0997-5DOI Listing
October 2020

Timing of physiotherapy following fragility hip fracture: delays cost lives.

Arch Orthop Trauma Surg 2018 Nov 27;138(11):1519-1524. Epub 2018 Jul 27.

Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, 39 Jabotinsky St., 49100, Petah Tikva, Israel.

Introduction: Post-operative physiotherapy (PT) following fragility hip fractures is intended to improve balance, gait, and muscle strength for enhanced functional outcomes. This study aims to assess whether postponing initiation of PT effects patients' outcomes during hospitalization and in the first 3 months following discharge.

Materials And Methods: A retrospective study comparing consecutive patients, 65 years and older, who were operated for fragility hip fractures between 2011 and 2016, within 48 h from admission, and started PT treatment either in the first post-operative day (POD1) or later (POD2-5). Patients were operated upon as soon as medically possible and in accordance with theater availability. All surgeries were performed outside of workday hours (either in the afternoon or during the weekend). Group allocation was established corresponding with the surgical day, as PT services are unavailable during weekends and holidays, and surgeries were performed daily. Primary outcomes were mortality either within hospital or in the post-operative year. Secondary outcomes were in-hospital complications, recurrent hospitalizations, and orthopedic complications within 3 months.

Results: 747 patients were included in the study; 525 patients started PT at POD1 and 222 had delayed PT. Patients' demographics, living arrangements, age-adjusted Charlsons' co-morbidity index, mobility, hemoglobin levels, and implant type were comparable. In-hospital mortality was significantly higher for the delayed PT group, 6.8 vs. 3.2% (OR 2.2, 95% CI 1.06-4.42, p value 0.034). One-year mortality, in-hospital complications, and the average number of 3 months' recurrent hospitalizations did not differ between groups. A trend for more orthopedic complications was noted in the delayed PT group (p = 0.099), and patients from this group were readmitted more often due to orthopedic surgery-related reasons (p = 0.031).

Conclusions: Post-operative delay in PT following fragility hip fracture surgery was related to increased risk for in-hospital mortality.
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http://dx.doi.org/10.1007/s00402-018-3010-1DOI Listing
November 2018

Relatively High Complication and Revision Rates of the Mayo Metaphysical Conservative Femoral Stem in Young Patients.

Orthopedics 2018 Jul 9;41(4):e516-e522. Epub 2018 May 9.

The Mayo metaphysical conservative femoral stem (Zimmer, Warsaw, Indiana) is a wedge-shaped implant designed to transfer loads proximally, reduce femoral destruction, and enable the preservation of bone stock in the proximal femur. Thus, it is a potentially preferred prosthesis for active, non-elderly patients who may require additional future surgeries. This retrospective case study analyzed the outcomes of consecutive patients who underwent total hip replacements with this stem between May 2001 and February 2013. All patients underwent clinical assessment, radiological evaluation for the presence and development of radiolucent lines, and functional assessment (numerical analog scale, Harris hip score, and Short Form-12 questionnaire). Ninety-five hips (79 patients) were available for analysis. The patients' mean age was 43 years (range, 18-64 years), and the mean follow-up was 97 months (range, 26.9-166 months). The postoperative clinical assessments and functional assessments revealed significant improvements. Sixteen patients (20.3%) had 18 orthopedic complications, the most common of which were an intraoperative femoral fracture and implant dislocation requiring revision surgeries in 10 hips (10.5%). Radiological analysis revealed evidence of femoral remodeling in 64 (67.4%) implants, spot welds (neocortex) in 35 (36.8%), and osteolysis in 3 (3.2%). These results suggest that the conservative hip femoral implant has an unacceptable complication rate for non-elderly patients. [Orthopedics. 2018; 41(4):e516-e522.].
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http://dx.doi.org/10.3928/01477447-20180503-01DOI Listing
July 2018

Arthroscopic rotator cuff surgery following shoulder trauma improves outcome despite additional pathologies and slow recovery.

Knee Surg Sports Traumatol Arthrosc 2018 Dec 4;26(12):3804-3809. Epub 2018 May 4.

Orthopedic Department, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Purpose: To compare the outcome, recovery and surgical findings after shoulder arthroscopy of clinically defined traumatic and non-traumatic rotator cuff pathology in middle-aged patients.

Methods: Of the patients who underwent rotator cuff surgery, 37 patients who reported a preceding shoulder injury related to their shoulder symptoms (traumatic group) were compared to a control group of 58 patients without a preceding injury (non-traumatic group), matched by age, body mass index and comorbidities. Data included demographic details, patient history, surgical findings, the Oxford Shoulder Score questionnaires and overall satisfaction from surgery.

Results: The mean follow-up time was 33.2 ± 14.4 months. More concomitant pathologies were found in the study group. The proportion of large and massive supraspinatus tears was double in the study group (43%) compared to the control group (22%). The Oxford Shoulder Score (OSS) improved significantly after surgery in both groups (p < 0.001) with no differences between groups in OSS and overall satisfaction from surgery. Patients in the study group felt recovered at an average time of 6.1 ± 4.6 months from surgery, while patients in the control group felt recovered at 4.2 ± 2.6 months (p = 0.02). Patients who were operated at the first 6 months after the injury had better improvement in OSS than patients who were operated later.

Conclusion: Surgical arthroscopy for rotator pathology of the shoulder in middle-aged patients improved pain and function regardless of a traumatic onset; however, earlier repair after trauma resulted in better outcome scores. Larger full-thickness tears and concomitant pathologies were more common after injury.

Study Design: Level III.
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http://dx.doi.org/10.1007/s00167-018-4969-4DOI Listing
December 2018

Morbidity and mortality after fragility hip fracture surgery in patients receiving vitamin K antagonists and direct oral anticoagulants.

Thromb Res 2018 06 26;166:106-112. Epub 2018 Apr 26.

Institution of Hematology, Coagulation Unit, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel.

Introduction: Early surgical treatment is recommended to reduce morbidity and mortality in patients with fragility hip fractures. Anticoagulation treatment poses a surgical challenge. While the action of vitamin K antagonists (VKAs) can be reversed, for direct oral anticoagulants (DOACs) antidote is only available for dabigatran. We aimed to assess the outcomes of patients treated with VKAs or DOACs undergoing surgical treatment for fragility hip fractures.

Materials And Methods: A retrospective study of patients presenting with proximal femoral fractures between January 2012 and June 2016. Patients with VKAs received vitamin-K. Primary outcomes were 1-year and in-hospital mortality. Secondary outcomes were time to surgery, in-hospital complications, need for blood transfusions and 1-year readmissions.

Results: Seven-hundred seventy-nine patients (796 hips) were included; 103 received VKAs, 47 DOACs and 646 no-anticoagulation. No difference between the 3 groups was noted with respect to patients' demographics or surgery type. Charlson's comorbidity index was higher for the DOACs group. Patients under anticoagulation were delayed to theater (Surgery < 48 h in 51% DOACs and 59% VKAs patients vs. 92% of no-anticoagulation, p < 0.001). Neither in-hospital nor 1-year mortality differed between groups. No other outcome measures differed, except for more wound infections in VKAs patients.

Conclusions: While preoperative anticoagulation delays surgery following fragility hip fractures, this delay was not found to be related to increased morbidity or mortality. DOACs-treated patients did not have adverse outcomes compared to VKAs-treated patients despite the irreversibility of their treatment.
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http://dx.doi.org/10.1016/j.thromres.2018.04.022DOI Listing
June 2018

Structured, Protocol-Based Pulse-Oximetry Measurement Improves the Evaluation of Hypoxemic Patients at Hospital Admission.

Isr Med Assoc J 2018 Mar;20(3):147-150

Department of Medicine 'T', Sheba Medical Center, Tel Hashomer, Israel, affiliated with Sackler Faculty of Medicine, Tel Aviv University; Tel Aviv, Israel.

Background: Accurate pulse oximetry reading at hospital admission is of utmost importance, mainly for patients presenting with hypoxemia. Nevertheless, there is no accepted or evidence-based protocol for such structured measuring.

Objectives: To devise and assess a structured protocol intended to increase the accuracy of pulse oximetry measurement at hospital admission.

Methods: The authors performed a prospective comparison of protocol-based pulse-oximetry measurement with non-protocol based readings in consecutive patients at hospital admission. They also calculated the relative percentage of improvement for each patient (before and after protocol implementation) as a fraction of the change in peripheral capillary oxygen saturation (SpO2) from 100%.

Results: A total of 460 patients were recruited during a 6 month period. Implementation of a structured measurement protocol significantly changed saturation values. The SpO2 values of 24.7% of all study participants increased after protocol implementation (ranging from 1% to 21% increase in SpO2 values). Among hypoxemic patients (initial SpO2 < 90%), protocol implementation had a greater impact on final SpO2 measurements, increasing their median SpO2 readings by 4% (3-8% interquartile range; P < 0.05). Among this study population, 50% of the cohort improved by 17% of their overall potential and 25% improved by 50% of their overall improvement potential. As for patients presenting with hypoxemia, the median improvement was 31% of their overall SpO2 potential.

Conclusions: Structured, protocol based pulse-oximetry may improve measurement accuracy and reliability. The authors suggest that implementation of such protocols may improve the management of hypoxemic patients.
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March 2018

[ACUTE ALCOHOL INTOXICATION IN AN EIGHT WEEKS OLD INFANT].

Harefuah 2017 Mar;156(3):139-141

The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer.

Introduction: Alcohol intoxication in infants is a life-threatening condition which requires early diagnosis and treatment. It may lead to multi-system injury, including mental deterioration, respiratory depression, cardiac arrhythmia, metabolic disorders and hypothermia. We present the case of an eight weeks old female infant who was admitted to the pediatric emergency department after ingesting 40 ml of vodka with her baby formula. She was initially apathetic, with blood alcohol levels of 149 mg/dl, yet fully recovered after a short period of time. We present this case in order to increase awareness of the possibility of alcohol intoxication in young infants.
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March 2017

[THE RELATIONSHIP BETWEEN OVERWEIGHT, OBESITY AND KNEE OSTEOARTHRITIS].

Harefuah 2016 Nov;155(11):668-671

Tel Aviv Sourasky Medical Center, Ichilov.

Introduction: The prevalence of overweight and obesity in the western world is growing, and with it there is a growing number of patients with osteoarthritis, a condition that leads to pain and disability. The association between body weight and osteoarthritis is mediated by both mechanical and humeral factors such as growth factors, hormones and mediators of the immune system. This review will present the mechanisms which lead to osteoarthritis, and will discuss available treatments which are suitable for the overweight and obese population, along with promising emerging new treatments.
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November 2016
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